THE BOSTON

MEDICAL AND SURGICAL JOURNAL.

E

VOL. XCVIII. - THURSDAY, JANUARY 3, 1878. ΝΘ. Ι.

LECTURES.

17 14 8

ANEURISM OF THE THORACIC AORTA.

BEING A CLINICAL LECTURE.

BY WM. PEPPER, M. D.,

Professor of Clinical Medicine in the University of Pennsylvania.

CASE I. The patient is a sailor, of middle age, and born in Germany. His health was unimpaired until about ten months ago, when he felt slight pains in the upper part of the right side of the chest, and complained of some shortness of breath upon exertion. He has a venereal history, and of late years has been frequently exposed to rough weather. Within the past ten months his symptoms have been gradually increasing, and he has been obliged for the last five months to give up all work and confine himself to bed. He has never had any cough, and there have been no sputa since he has been sick.

An examination of the heart shows that its action is much excited, that the area of impulse is enlarged, and that the maximum impulse is felt in the sixth interspace, one inch to the left of the left nipple. The area of cardiac dullness upon percussion is increased. The heart extends up to the third rib, down to the level of the stomach, and from the left border of the sternum to one inch beyond the left nipple. This proves that the size of the heart has increased. The first sound of the heart is roughened. There is no valvular murmur heard at the apex, but I find a slight murmur at the base. This murmur is heard high up and at the anterior border of the axilla, and is also feebly transmitted to the inferior angle of the left scapula behind. There may be some slight mitral regurgitation, therefore, in addition to the functional disturbance of the heart. The murmurs are strongest in the second interspace, two inches to the right of the sternum. They, however, are very much weaker at the aortic cartilage, and do not follow at all the laws of the transmission of mitral or aortic murmurs.

The lungs are entirely healthy. The right upper chest is slightly fuller than the left. Upon examination of the right upper chest, where the pain is located, I discover a strong pulsation and thrill. These signs are situated at the exact point mentioned above as that where the mur

murs are loudest. This spot is two inches to the right of the sternum and four inches upwards and to the right of the heart's impulse. On percussing the chest I get resonance over the upper part of the left chest, but on the right side there is flatness, extending from the lower margin of the third rib up to the clavicle, inwards beyond the middle of the sternum, and outwards to the junction of the middle and outer third of the clavicle. There is evidently a pulsating tumor exactly over the site of the arch of the aorta.

This tumor certainly is not the heart. It must be either some body with pulsation of its own, or some solid body which the heart hits at each stroke and to which it transmits its impulse. Can this be a tumor which receives and transmits the impulse of the heart? We rarely find a tumor in this part of the chest, for the simple reason that there are no glands here which could become the site of a tumor. On auscultation over the site of pulsation and thrill I hear a hoarse, strong, blowing murmur. This murmur cannot be heard over the heart. Putting those facts together we are able to diagnosticate the existence of an aneurism. No such enlargement is possible in the course of a vein. From the position of the aneurism it must be one involving the outer wall of the arch of the aorta and possibly the mouth of the innominate artery. This aneurism is as large as the head of a child at term. It is the result, probably, of atheroma of the coats of the innominate artery and aorta, brought on by syphilitic arteritis.

The patient is unusually free from the complications which commonly attend an aneurism of the aorta and innominate. Such an aneurism may press upon the trachea, causing cough, dyspnoea, and in some cases aphonia; or upon the pneumogastric nerve, producing paralysis of its branches, with hiccough, belching, etc. Again, by pressure on the œsophagus, the reception of food might be seriously impeded, if not entirely prevented. This man presents none of these symptoms. In some cases of aneurism of the aorta, there is a difference in the two radial pulses, owing to interference with the passage of the blood on one side or the other of the aorta. In this case the two pulses are pretty nearly alike; the right is perhaps a shade smaller than the left. Sometimes there will be pressure on the neighboring sympathetic ganglia, which regulate the vasa vasorum. At times there is an inequality in the circulation on the two sides of the head, as shown in the size of the pupils, one being larger than the other. There is no difference in the size of this man's pupils. The aneurism in this case, fortunately, does not interfere with any important structures. It is gradually, however, leading to absorption of the ribs above its site.

As there is great danger of the sac bursting, treatment must be directed (1) to the stoppage of the progress of the atheroma, and (2) to the diminution of blood pressure. The only drug which can

favorably affect the atheroma is iodide of potassium. This should be given in doses beginning with fifteen grains three times a day. The patient must be rigorously confined to bed. To reduce the blood pressure, from three to five drops of the tincture of the root of aconite should be given thrice daily. Under this treatment in the present instance the pulse has been reduced from 96 to 70 in the minute, the pain and palpitation are all gone, the impulse is less strong, and the aneurismal murmur is much softer and weaker. All these signs point to a gradual solidification of the contents of the sac.

To diminish the mass of the blood, thus reducing the amount of red corpuscles and of albumen, and to increase the amount of fibrin, and so favor the coagulation of the blood in the sac, the patient should be placed upon a reduced diet, - about one half as much as would amount to full rations. I am allowing this man at breakfast two ounces of bread and a little coffee, at dinner two ounces of meat and a little bread, and at supper two ounces of bread. This diet has reduced his weight from one hundred and sixty-nine to one hundred and forty-five pounds, and has greatly increased his comfort, rendering sleep easier. I hope thus to bring about coagulation without surgical interference.

[Three weeks ago the man spat blood, and I was afraid the sac had burst. The patient was kept perfectly quiet; gallic acid was administered internally, and ice applied to the chest. Under this treatment the hemoptysis stopped immediately. It was probably only the result of a local congestion.]

CASE II. Also a sailor. The patient came to port about one month. ago. For the past three weeks he had been suffering from cough, general weakness, dyspnoea, and excited action of the heart. There had not been, during his sickness, any expectoration. His temperature had ranged as high as 101° F., and he had complained of considerable pain in the left side of his chest. He could not breathe easily if he lay down, and so he sat up all through his illness. Percussion of the right chest revealed healthy resonance. There were no râles, and the respiratory murmur was good. Percussion over the upper lobe of the left lung elicited perfectly solid dullness extending all the way down to the fourth rib. The resonance was good, however, in the left axilla. The apex beat of the heart was outside the line of the left nipple. The heart was very much enlarged, and its sounds were feeble. No heart murmur at all could be heard upon auscultation of the back of the chest. Auscultation over the apex of the left lung in front showed entire absence of respiratory sounds, as if it were completely solidified or the sounds were muffled by an intervening pleural effusion. Behind there was a blowing murmur heard above and some slight bronchial breathing below. The train of symptoms and physical signs, together with the entire absence of any satisfactory history of the case, rendered